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How would you code canceled procedure??

  1. #1
    Default How would you code canceled procedure??
    Medical Coding Books
    Hi Everyone,

    Any ideas on how to code a procedure that wasn't done? Pt made it into the room, and Fentanyl was given; however, they couldn't proceed with the angiogram because of his heart rate. This is the dictated note:
    Male with left lower extremity claudication, presents
    for angiography and endovascular management.
    TECHNIQUE: The patient was positioned on the angiography table. It was
    found that the patient's heart rate was approximately 38-42 beats per
    minute. The patient was asymptomatic with this heart rate. Previous notes
    dating back to xxxx 2014 indicate a heart rate of 64 beats per minute.
    The case was discussed with Dr. xxxx, and at his
    recommendation, the procedure was postponed, and patient will be evaluated
    by the cardiologist at xxx. A 12 lead EKG was ordered. The
    patient and the patient's wife were instructed the issues at hand and after
    the patient's cardiac status is cleared, the patient will be rescheduled
    for endovascular intervention.
    We've always been told that you only code as far as they got, which what we have is 75710-74 (do you agree?), but need a surgical code. Since we don't know what the cath placement would have been, we don't know what to use for this. Any thoughts/opinions are greatly appreciated.

  2. #2
    Location
    Columbia, MO
    Posts
    12,907
    Default
    Quote Originally Posted by iamlou View Post
    Hi Everyone,

    Any ideas on how to code a procedure that wasn't done? Pt made it into the room, and Fentanyl was given; however, they couldn't proceed with the angiogram because of his heart rate. This is the dictated note:
    Male with left lower extremity claudication, presents
    for angiography and endovascular management.
    TECHNIQUE: The patient was positioned on the angiography table. It was
    found that the patient's heart rate was approximately 38-42 beats per
    minute. The patient was asymptomatic with this heart rate. Previous notes
    dating back to xxxx 2014 indicate a heart rate of 64 beats per minute.
    The case was discussed with Dr. xxxx, and at his
    recommendation, the procedure was postponed, and patient will be evaluated
    by the cardiologist at xxx. A 12 lead EKG was ordered. The
    patient and the patient's wife were instructed the issues at hand and after
    the patient's cardiac status is cleared, the patient will be rescheduled
    for endovascular intervention.
    We've always been told that you only code as far as they got, which what we have is 75710-74 (do you agree?), but need a surgical code. Since we don't know what the cath placement would have been, we don't know what to use for this. Any thoughts/opinions are greatly appreciated.
    First are coding for the provider or the facility? 74 is a modifier for the facility only. Second if a code does describe the procedure as far as it went then you use that code with no modifier.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    If the procedure was cancelled due to the well being of the patient you would code the cpt code for the procedure with an appropriate modifier indicating that the procedure was not completed due to an event that the provider felt was a threat to the patient. For the physician billing that modifier would be 53 but if coding for the facility it would be modifier would be either 73 or 74.

  4. #4
    Default
    Thanks, Carol. It's for facility. Coding the procedure is the problem. They only got as far as sedating the pt. They were going to do an extremity angio, that's where we got the 75710-74 for the radiology portion, but we don't know what to use for the surgical portion. Normally with an angio we would put the cath placement, but since they didn't even puncture the femoral, we have nothing. Maybe we should put 36140-74, since that's most likely where they would begin? Thanks again for taking the time to read this.

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